Reporting of Physicians' or Investigators' Choice of Treatment in Oncology Randomized Clinical Trials

A novel framework to assess haematology and oncology registration trials: The THEOREMM project

BACKGROUND

Methodological limitations affect a significant number of oncology and haematology trials, raising concerns about the applicability of their results. For example, a suboptimal control arm or limited access to best care upon progression may skew the trial results toward a benefit in the experimental arm. Beyond the fact that such limitations do not prevent drugs reaching the market, other assessment tools, such as those developed by professional societies-ESMO-MCBS and ASCO Value Framework-do not integrate these important shortcomings.

METHODS

We propose creating a novel framework with the scope of assessing registration cancer clinical trials in haematology and oncology (randomized or single arm)-that is trials leading to a marketing authorization. The main steps of the methods are (1) assembling a scientific board; (2) defining the scope, goal and methods through pre-specified, pre-registered and protocolized methodology; (3) preregistration of the protocol; (4) conducting a scoping review of limitations and biases affecting oncology trials and assessing existing scores or methods; (5) developing a list of features to be included and assessed within the framework; (6) assessing each feature through a questionnaire sent to highly cited haematologists and oncologists involved in clinical trials; and (7) finalizing the first version of framework.

RESULTS

Not applicable.

CONCLUSIONS

Our proposal emerged in response to the lack of consideration for key limitations in current trial assessments. The goal is to create a framework specifically designed to assess single trials leading to marketing authorization in the field of oncology and haematogy.

Expert Perspectives on Controversies in Metastatic Castration-Resistant Prostate Cancer Management: Narrative Review and Report of the First US Prostate Cancer Conference Part 2

Background

Management strategies for metastatic castration-resistant prostate cancer (mCRPC) have rapidly shifted in recent years. As novel imaging and therapeutic approaches have made their way to the clinic, providers are encountering increasingly challenging clinical scenarios, with limited guidance from the current literature.

Materials and Methods

The US Prostate Cancer Conference (USPCC) is a multidisciplinary meeting of prostate cancer experts intended to address the many challenges of prostate cancer management. At the first annual USPCC meeting, areas of controversy and consensus were identified during a 2-day meeting that included expert presentations, full-panel discussions, and postdiscussion responses to questions developed by the USPCC cochairs and session moderators.

Results

This narrative review covers the USPCC expert discussion and perspectives relevant to mCRPC, including neuroendocrine/aggressive-variant prostate cancer (NEPC/AVPC). Areas of broad agreement identified among USPCC experts include the benefits of poly (ADP-ribose) polymerase (PARP) inhibitors for patients with BRCA1/2 mutations, the use of radioligand therapy in patients with prostate-specific membrane antigen (PSMA)-positive mCRPC, and the need for clinical trials that address real-world clinical questions, including the performance of novel therapies when compared with modern standard-of-care treatment. Ongoing areas of controversy and uncertainty included the appropriateness of PARP inhibitors in patients with non-BRCA1/2 mutations, the optimal definition of PSMA positivity, and systemic therapies for patients with NEPC/AVPC after progression on platinum-based therapies.

Conclusions

The first annual USPCC meeting identified several areas of controversy in the management of mCRPC, highlighting the urgent need for clinical trials designed to facilitate treatment selection and sequencing in this heterogeneous disease state.

Lutetium-177-PSMA-617 in Metastatic Castration-resistant Prostate Cancer: Limitations of the VISION Trial

Lu-PSMA was approved in the USA for patients with prostate-specific membrane antigen-positive metastatic castration-resistant prostate cancer already treated with androgen receptor pathway inhibition and taxane-based chemotherapy on the basis of results from VISION. Three limitations affected the control arm in VISION: choice of the standard of care was limited, some patients initially deemed ineligible for taxane later received it, and there was a high attrition rate. VISION is an example of the many challenges in modern oncology trials. The direct and indirect costs of Lu-PSMA also mean that this therapy is likely to be out of reach for many nations, deepening global inequities in health care access.

Dose modification rules and availability of growth factor support: A cross-sectional study of head-to-head cancer trials used for US FDA approval from 2009 to 2021

AIM OF THE STUDY

Different drug modification rules or growth factor support guidance may affect the results in oncology randomised controlled trials. We aimed to estimate the prevalence of unequal rules for dose modification rules or the use of myeloid growth factors in head-to-head registration Food and Drug Administration trials.

METHODS

This cross-sectional analysis included all head-to-head registration randomised controlled trials leading to a US Food and Drug Administration approval between 2009 and 2021. Trials examined anti-cancer drugs in the advanced or metastatic setting where a comparison could be made between arms regarding either dose modification rules or myeloid growth factors recommendations. Sixty-two registration trials met inclusion criteria. Information abstracted for each trial included tumour type, setting, phase, and type of sponsor. We assessed, according to pre-specified rules, imbalance in drug modification rules, myeloid growth factors recommendations or both.

RESULTS

We find 40 of 62 (65%) selected trials have unequal rules for dose medication, granulocyte colony-stimulating factor (G-CSF) use or both. Six trials (10%) had rules favouring the control arm, while 55% of selected trials (34/62) favoured the experimental arm. Among these, 50% (17/34) had unequal drug modification rules, 41% (14/34) had unequal G-CSF rules and 9% contained both (3/34).

CONCLUSION

We find that 55% of trials testing anti-cancer drugs against each other used protocol rules that favoured the experimental arm. This leaves open the question of whether new molecules are truly superior to older molecules or if instead different outcomes are due to more aggressive dosing or growth factor support. Trials should utilise equal rules for dose medication and G-CSF support.

Tebentafusp in first-line melanoma trials: An outperforming outlier

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Uveal melanoma is distinct from other melanomas.

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Tebentafusp provided an overall survival benefit in HLA-A*02:01-positive patients with metastatic uveal melanoma.

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With discrepancy between overall survival and progression-free survival, the result is an outlier in melanoma trials.

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Confirmatory trials are needed for this compound.

Uveal melanoma is distinct from other melanomas. In the advanced and metastatic stages, little to no improvement have been seen over time. Tebentafusp is a novel mechanism of action bispecific gp100 peptide-HLA-directed CD3 T-cell engager fusion protein (“-fusp”). Tebentafusp was granted full approval on January 25th 2022 in the setting of HLA-A*02:01-positive adult patients with unresectable or metastatic uveal melanoma. The approval was based on the overall survival advantage of tebentafusp over physician's choice therapy, in previously untreated uveal melanoma patients, based on the IMCgp100-202 trial. While we welcome positive results for this unmet need, three issues are raised by the trial. First, the control arm was restricted, precluding important options. Second, post-progression treatment was provided to a smaller fraction of patients than in real-life, which raises the question of whether overall survival was negatively impacted by limited care after the trial ended. Finally, the discrepancy between overall survival and progression-free survival benefit is an outlier in the context of previous melanoma trials. While it is clear that tebentafusp has an important role to play in this tumor type, the exact line is not yet well known. Confirmatory trials are needed for this compound.